Overview

It has been known for more than 150 years that physicians have an increased propensity to die by suicide. It was estimated in 1977 that on average the United States loses the equivalent of at least one small medical school or a large medical school class to suicide.
[1] Exact numbers are not known. Although it is impossible to estimate with accuracy because of inaccurate cause of death reporting and coding, the number most often used is approximately 3-400 physicians/year, or perhaps a doctor a day. Of all occupations and professions, the medical profession consistently hovers near the top of occupations with the highest risk of death by suicide.

Sadly, although physicians globally have a lower mortality risk from cancer and heart disease relative to the general population (presumably related to knowledge of self care and acess to early diagnosis), they have a significantly higher risk of dying from suicide, the end stage of an eminently treatable disease process. Perhaps even more alarming is that, after accidents, suicide is the most common cause of death among medical students.

In every population, suicide is almost invariably the result of untreated or inadequately treated depression or other mental illness that may or may not include substance or alcohol abuse, coupled with knowledge of and access to lethal means.
[2] Depression is at least as common in the medical profession as in the general population, affecting an estimated 12% of males and up to 19.5% of females.
[3, 4] Depression is even more common in medical students and residents, with 15-30% of them screening positive for depressive symptoms.
[5, 6, 7, 8, 9] This is not an isolated North American phenomenon. Studies from Finland, Norway, Australia, Singapore, China, Taiwan, Sri Lanka, and others have shown increased prevalence of anxiety, depression, and suicidality among students and practitioners of medicine.
[10, 11, 12, 13]

However, because of the stigma associated with depression in almost all cultures, which seems to be greatly magnified among medical practitioners, self reporting likely underestimates the prevalence of the disease in medical populations. Indeed, although physicians seem to have generally heeded their own advice about avoiding smoking and other common risk factors for early mortality, they are decidedly reluctant to address depression, a significant cause of morbidity and mortality that disproportionately affects them. Depression is also a leading risk factor for myocardial infarction in male physicians, and it may play a role in immune suppression thus increasing the risk of many infectious diseases and cancer.
[14, 15, 16, 17, 18, 19, 20, 21]

Because of their greater knowledge of and better access to lethal means, physicians have a far higher suicide completion rate than the general public. The most reliable estimates of successful completion of suicide range from 1.4-2.3 times the rate achieved in the general population. Although female physicians attempt suicide far less often than their counterparts in the general population, their completion rate equals that of male physicians and, thus, far exceeds that of the general population (2.5-4 times the rate by some estimates).
[3, 4]

A reasonable assumption is that underreporting of suicide as the cause of death by sympathetic colleagues certifying death may well skew these statistics; consequently, the real incidence of physician suicide is probably somewhat higher than the prevailing estimate.

The most common psychiatric diagnoses among physicians who complete suicide are affective disorders (eg, depression and bipolar disease), alcoholism, and substance abuse. The most common means of suicide by physicians are lethal medication overdoses and firearms.
[22, 23]

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Depression in Physicians

Physicians are demonstrably poor at recognizing depression in patients, let alone themselves. Furthermore, they are notoriously reluctant to seek treatment for any personal illness. This may be especially true in the case of potential mental illness. A survey of American surgeons revealed that although 1 in 16 had experienced suicidal ideation in the past 12 months, only 26% had sought psychiatric or psychologic help. There was a strong correlation between depressive symptoms, as well as indicators of burnout, with the incidence of suicidal ideation. More than 60% of those with suicidal ideation indicated they were reluctant to seek help due to concern that it could affect their medical license.
[24] Other studies
[25] reveal that this concern about regulatory intervention is a very common concern hampering help seeking for mental health issues. In addition, other research suggests that 1 in 3 physicians has no regular source of medical care.
[26]

Reluctance to recognize depression in a colleague is a tendency shared and imposed by other physicians, who may be well intentioned, habitually emotionally distanced from colleague/competitors, and/or feeling temporarily vulnerable themselves. Even when healthy, physicians find it difficult to ask for help of any kind. When they are depressed and feeling less than adequate, they find it even more difficult—and when they can bring themselves to ask, they sometimes find that the help they need is remarkably difficult to obtain.

To some extent, however, physicians’ reluctance to reach out is self-imposed. They may feel an obligation to appear healthy, perhaps as evidence of their ability to heal others. Inquiring about another physician’s health can shatter this mutual myth of invulnerability, and volunteering support or assistance unasked may seem like an affront to a colleague’s self-sufficiency. Thus, the concerned colleague or partner may say nothing, while wondering privately if the colleague has become impaired.

Unconsciously defending against this painful vulnerability, partners or significant others may also fail to notice significant depression or withdrawal, attributing behavioral changes instead to stress or overwork. Nearly every article about a physician’s suicide contains a quotation from some close contact, occasionally a spouse, saying something like, “I never had any idea that he/she was suffering.”
[27] Of course, many physician obituaries omit the fact that the “sudden death” was a completed suicide.

Depressed physicians who do reach out may find that they receive only limited understanding or sympathy from colleagues. There is no specialized training for a physician's physician (as there is, for example, for the pope's confessor). Most physicians either shrink from this role or perform it poorly.

For many experiencing depression, the early symptoms are physical. A physician unable to diagnose his or her own symptoms commonly feels incompetent. To admit one’s inability to diagnose oneself to another colleague is to admit failure. When this admission is met with avoidance, disbelief, or derision by a reluctant treating physician, it can only reinforce a depressed physician’s feelings of worthlessness and hopelessness.

Physicians find it painful to share their experience of mental illness with others and know that doing so is somewhat risky; therefore, published accounts of physician depression are very difficult to find. However, recent highly publicized cases of resident and physician suicides and subsequent sharing of experiences of depression by physicians
[28] suggest that either the incidence of depression is rising, or we are beginning to be more able to admit and to address the immensity of the problem.

Marriage is in most popultations considered to be an effective buffer to emotional distress. This does not seem to be true for women physicians.
[23] It is believed that physician divorces are less frequent compared to the general population, but marital problems are common, perhaps in part because of the tendency of physicians to postpone addressing marital problems and to avoid conflict in general.
[29] Marital problems, separation, or divorce can certainly contribute to depressive symptoms, which can increase the likelihood of suicidality if unaddressed.

Physicians are a "high control" population (along with law enforcement, lawyers, and clergy), and situations that decrease physicians' ability to control their environment, workplace, or employment conditions predictably play a higher role in physician suicide than they do in lower control populations.
[23] The massive changes that have taken place in medicine in the past several decades, leading to increased workloads and regulatory requirements coupled with decreased ability to control income and patient safety and liability concerns also predictably lead to higher levels of stress, job dissatisfaction, burnout, and depression in physicians.

Litigation-related stress can precipitate depression and, occasionally, suicide.
[30, 31] The suicide note of a Texas emergency physician, written the day after he settled a malpractice case, read, “I hope that my death will shed light on the problem of dishonest expert testimony.”
[32] Some physicians have completed suicide upon first receipt of malpractice claims, after judgments against them in court, or after financially motivated settlements foisted upon them by a malpractice insurer solely in order to cut the insurer’s losses. Any settlement in a malpractice case is by law reported to the National Practitioner Data Bank, which is yet another source of distress and stigma that can contribute to depression.

Other physicians have attempted or completed suicide in response to employment discrimination relating to judgments or settlements or upon the realization that they are no longer able to practice because of discrimination by liability insurers who refuse to insure them because of past judgments or settlements or because of regulatory licensure investigations or limitations or databank reporting,
[33, 34] or in the setting of forced hospitalization or treatment for chemical dependency when a dual diagnosis has not been justified under medically accepted standards.
[35]

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Problems With Treating Physician Depression

Many clinicians are uncomfortable treating fellow physicians, especially in the realm of mental health.
[36] The “VIP syndrome,” characterized by well-intentioned, but superficial or inadequate, treatment based on collegiality and concerns about confidentiality, can detract from the effectiveness of therapy.

Mental health experts who have studied physician depression and suicide stress that immediate treatment and confidential hospitalization of suicidal physicians can be lifesaving—more so than in other populations.
[37] Yet, the specters raised by this approach—the fear of temporary withdrawal from practice, of lack of confidentiality and privacy in treatment, or of loss of respect in the community—are often major impediments that hinder physicians from reaching out in a time of crisis and seeking effective treatment.
[33, 38, 39]

Physicians who have reported depressive symptoms (even those for which they are receiving effective treatment) to their licensing boards, potential employers, hospitals, and other credentialing agencies have experienced a range of negative consequences, including loss of their medical privacy and autonomy, repetitive and intrusive examinations, licensure restrictions, discriminatory employment decisions, practice restrictions, hospital privilege limitations, and increased supervision.
[40, 41, 42, 38, 39, 43, 25]

Such discrimination can immediately and severely limit physicians’ livelihoods as well as the financial stability of their families. For this reason, well-meaning colleagues or family members who are aware of the depression sometimes discourage physicians from seeking help.

Licensure concerns

Medical licensure applications and renewal applications frequently require answers to broad-based, time-unlimited questions regarding the physician’s mental health history without regard to current impairment, and courts have determined that they are impermissible, because the resultant examinations and restrictions constitute discrimination under Title II of the Americans with Disabilities Act (ADA) based on stereotypes.
[44, 45, 46, 47, 48, 42, 49] However, impermissibly broad parameters still persist in almost half of all licensure applications' mental health questions.
[50]

Most states have physician health programs that may or may not be associated with the medical licensing authority, and many have regulations that allow a physician enrolled in a physician health program who is compliant with treatment to check “no” on the mental health questions on licensure applications. However, physicians who are contemplating or in need of treatment are almost universally unaware of such "safe harbor" provisions.

Most physicians assume that any state agency or treating physician will share confidential information about them to the licensing authority.
[51] Additionally, any lack of disclosure on an employment or credentialing application can be cited as grounds for termination or decredentialing.

Insurance concerns

Discrimination in obtaining insurance coverage is a common, but little publicized problem for physicians with mental illness. Health, disability, life, and liability insurance may all be denied to a physician who admits to depression.

Even if disability insurance has previously been procured, its use may subject physicians to repeated humiliating and invasive examinations by detached and dubious “independent medical examiners” for the insurer, whose motivation is to cut company losses. Many physicians affected by mental illness feel that insurers expect them to adhere to the standard prescription “physician, heal thyself.”

Self-treatment

Despite the protections afforded by law to citizens and other professionals who have disabilities, the potentially devastating effects triggered by a physician’s self reporting of depression may delay or, in effect, preclude appropriate treatment.

Although everyone knows that a doctor who treats himself or herself "has a fool for a patient,” we also know that most physicians treat themselves anyway, at least on occasion. This is especially likely when the physician believes that the consequences of seeking treatment may subject him or her to stigma, shame, or worse.

Because many states require reporting by other licensed physicians of a physician who may be suffering from a potentially impairing condition, physicians can be reluctant to seek treatment from colleagues, or from utilizing their insurance coverage, or even from using their own names when seeking treatment. A physician whose thought processes are clouded by depression and the anticipated consequences of seeking treatment for it may honestly believe that self-treatment is the only safe option. One analysis of physician suicide data relative to nonphysician victims revealed a much lower prevalence of antidepressant medication in the blood of physician victims, which is an objective indication of the truth that physicians do not receive mental health care in proportion to their need.
[23] Too often, however, attempts at self-treatment are unsuccessful. Failure to obtain consultation and treatment for depression needlessly and significantly increases the risk of physician suicide.

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Depression in Medical Trainees

Prospective medical students and residents are extremely unlikely to report a history of depression during highly competitive selection interviews. The prevalence of depression in these populations and in medical student and postgraduate trainees is unknown, but it is estimated to range from 15-30%.
[5, 6, 7, 8, 9, 52] After accidents, suicide is the most common cause of death among medical students. In one study, 9.4% of fourth-year medical students and interns reported having suicidal thoughts in the previous two weeks.
[6]

One report has suggested that depression is not uncommon in pediatric residents (up to 20% self reported in 3 programs). This preliminary study found that residents who experienced depression may be as much as 6 times more likely than nonaffected controls to make medication errors.
[53] Other studies have confirmed the association of depression with self-perceived medication and other errors.
[54] Recently skyrocketing rates of burnout being reported among physician trainees and physicians have garnered attention
[55] . Although burnout does not necessarily lead to depression, some of the symptoms are similar; and burnout probably contributes to the development or onset of depression in those who are predisposed.

Stressful aspects of physician training—such as long hours, having to make difficult decisions while being at risk for errors due to inexperience, learning to deal with death and dying, frequent shifts in workplace, and estrangement from supportive networks, such as family—could add to the tendency toward depressive symptoms in trainees.

Harassment and belittlement by professors, higher-level trainees, and even nurses contribute to mental distress of students and development of depression in some.
[56] Even positive workplace changes, such as translocations to secure further training or job advancement, can contribute to job-related stress. Suicide in medical trainees is most likely to occur just prior to beginning clinical rotations, or prior to or at the beginning of residency.

A few schools are implementing programs to recognize and deal with depression and other stresses in medical trainees.
[57, 58, 7, 59, 60, 9] The American Foundation for Suicide Prevention has created a video on the topic for physicians and other medical trainees.
[61]

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Education and Resources

Depression, like substance abuse, is not only more common in physicians than in the general public but also more readily treatable as a rule. This is because of physicians’ strong self motivation to continue successful pursuit of a professional calling, which is an important source of their self-esteem.

More education is needed regarding this disease and its disproportionate and needless toll on the medical profession, beginning in the earliest stages of physician training.
[62] In addition, there is an urgent need to change the attitudes of those in health care (including those in the regulatory system), as well as the attitudes of the general public, toward mental illness. Such changes might encourage physicians to be more receptive to a diagnosis of depression and enable them to feel free to seek treatment without the fear of repercussion.

Physicians themselves need to be aware of the existence of physician health programs in nearly every state and province, which allow a physician who is compliant with treatment to avoid disclosing depression or other stable illnesses that do not interfere with ability to practice to licensing authorities.
[63] But they also need to be circumspect in dealing with these agencies, and to proceed with caution and full knowledge of the process before entering into it, because of the risk of being entailed into substance abuse programs, if no concomitant substance use disorder exists.
[49]

The American Medical Association had a 2009 directive from its House of Delegates to work with the Federation of State Medical Boards and Federation of State Physician Health Programs to study barriers to effective utilization of physician health programs, including assurance of confidentiality safeguards, and to educate members and others regarding the relationships between state licensing authorities and physician health programs. It is unclear what if any effect this activity has had on physician willingness to seek help for mental illnesses. However, the AMA and other organizations have realized that there is an emerging crisis of burnout in physicians and medical trainees, and are taking steps to address at least the burnout component.

For further information and resources related to physician depression and suicide, consult the American Foundation for Suicide Prevention (at www.afsp.org) and Black-Bile (at www.black-bile.com). (The latter website is named for the English translation of the Greek words melas [black] and khole [bile], from which the word melancholy is derived.) Information on litigation-related stress, along with related materials and resources, can be found at www.mdmentor.com.